KAREN GINSBURG, LCSW
255 South 17th St, Suite 1602,
Philadelphia PA 19103
kginsburg.lcsw@gmail.com
Licenses: NY: LCSW:077234-1
PA: LCSW: CW016616
EIN: 26-1468208 NPI:1962563486
917-349-1671

I, , authorize Karen Ginsburg, LCSW,
to discuss, (verbally and in writing), with the person/s, office, agency, or institution listed
below any relevant information that we have been spoken about during psychotherapy.
Furthermore, I authorize Karen Ginsburg, LCSW, to receive any relevant information from
the person/s, office, agency or institution listed below.

For the following reason(s): Coordination of care
List person, office, agency or institution below. Please include their contact information:

The purpose of this disclosure of information is to improve assessment and treatment
planning, share information relevant to treatment and when appropriate, coordinate
treatment services.

Revocation

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to Karen Ginsburg, LCSW at 255 South 17th St, Suite 1602, Philadelphia PA 19003, kginsburg.lcsw@gmail.com. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.

Unless sooner revoked, this authorization expires one year from today's date, on __________, or as otherwise noted.

Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.

I will be given a copy of this authorization for my records.

If you are signing as a personal representative of an individual, please describe your authority to act for this individual (power of attorney, healthcare surrogate, etc.).